PROGRAM OVERSIGHT amp COMPLIANCE BRANCH IMPROVING DOCUMENTATION FOR ACUTE PSYCHIATRIC INPATIENT HOSPITAL SERVICES THE MEDICAL SPECIALTY MENTAL HEALTH SERVICES PROGRAM AugustSeptember 2015 ID: 908398
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DEPARTMENT OF HEALTH CARE SERVICESPROGRAM OVERSIGHT & COMPLIANCE BRANCH IMPROVING DOCUMENTATION FOR ACUTE PSYCHIATRIC INPATIENT HOSPITAL SERVICES
THE MEDI-CAL SPECIALTY MENTAL HEALTH
SERVICES PROGRAM
August/September 2015
Slide2IMPROVING INPATIENT DOCUMENTATIONAGENDAStatutory, Regulatory and Contractual Bases for OversightThe Language We UseMedical Necessity Criteria for AdmissionDiagnosisIndications for Admission/Impairment CriterionFocus of Treatment RequirementLevel of Care RequirementEfficacy RequirementMedical Necessity for Continued Stay ServicesIndications
Guidance and Recommendations2
Slide3IMPROVING INPATIENT DOCUMENTATIONPlans of CareRequirements: Federal and ContractualGuidance and RecommendationsAdministrative Day Services Documentation RequirementsGuidance and RecommendationsA Reminder Regarding Interpreter ServicesExamples of Documentation Deficiencies and Some Recommendations
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Slide44IMPROVING INPATIENT DOCUMENTATIONINTRODUCTIONThe information in this PowerPoint is based on:(1) The triennial reviews of the 18 Short-Doyle/Medi-Cal acute psychiatric inpatient hospitals; and (2) The adjudication of second level Treatment Authorization Request (TAR) appeals. Between these two areas, we review documentation for approximately 4,500 inpatient hospital
days per year.
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IMPROVING INPATIENT DOCUMENTATIONPursuant to Section 1810.380 of Title 9 of the California Code of Regulations (CCR), the State Department of Health Care Services (DHCS) is responsible for monitoring the 18 Short-Doyle/Medi-Cal acute psychiatric inpatient hospitals and the Mental Health Plans (MHPs) with which they are associated to ensure their compliance with the provisions of the following:Section 1820.205 of CCR Title 9, “Medical Necessity Criteria for Reimbursement of Psychiatric Inpatient Hospital Services” Section 1820.220 of CCR Title 9, “MHP Payment Authorization by a Point of Authorization”Section 1820.230 of CCR Title 9, “MHP Payment Authorization by a Utilization Review Committee”Sections 5325.1 and 5325.1(a) of the Welfare and Institutions Code, “Same Rights and Responsibilities Guaranteed Others; Discrimination by Programs or Activities Receiving Public Funds; Additional Rights”
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IMPROVING INPATIENT DOCUMENTATIONSection 456.180 of Title 42 of the Code of Federal Regulations, “Individual Written Plan of Care”Sections 456.201 through 456.238 of Title 42 of the Code of Federal Regulations, Requirements for Utilization Review PlansSections 456.241 through 456.245 of Title 42 of the Code of Federal Regulations, Requirements for Medical Care Evaluation Studies
Slide7IMPROVING INPATIENT DOCUMENTATIONProvisions of the contract between DHCS and the MHPsTable 2 - Included ICD-9 Diagnoses - Hospital Inpatient Place of Service 290.12 – 290.21 299.10 - 300.15 308.0 – 309.9
290.42 – 290.43 300.2 - 300.89 311 – 312.23 291.3 301.0 - 301.5 312.33 - 312.35 291.5 - 291.89 301.59 - 301.9 312.4 – 313.23 292.1 - 292.12 307.1 313.8 – 313.82 292.84 – 292.89 307.20 - 307.3 313.89 - 314.9 295.00 – 299.00 307.5 - 307.89 787.6 7
Slide8IMPROVING INPATIENT DOCUMENTATIONIn addition, DHCS is responsible for monitoring the MHP Points of Authorization to ensure that they are processing Treatment Authorization Requests (TARs) in accordance with Section 438.210 of Title 42 of the Code of Federal Regulations as part of the triennial system reviews, and also receives and adjudicates second level TAR appeals from fee-for-service acute psychiatric inpatient hospitals.8
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THE LANGUAGE WE USEThe biggest problems reviewers encounter is documentation which is:UnclearVagueNot Behaviorally SpecificYou should:AVOID JARGONUSE LANGUAGE WHICH IS BEHAVIORALLY SPECIFICUSE VERBS RATHER THAN ADJECTIVESMAKE SURE WHAT YOU WRITE IS CLEAR
Slide1010Example of a Note Using Jargon The patient was impulsive and aggressive during community meeting, and exhibited poor impulse control on at least three occasions. Following group, the patient approached the nursing station, posturing aggressively, and spoke to the charge nurse in a threatening manner. His mood was labile
, his behavior unpredictable. When redirected, he returned to the day room where he was noted to be sullen. After approximately 15 minutes, the patient became sexually inappropriate and had to be asked to return to his room. He continued to be disruptive for the remainder of the shift.
Slide1111THE LANGUAGE WE USEDespite the fact that this paragraph contains six syntactically and grammatically correct sentences, it conveys very little precise meaning. What do we really know about the patient’s behavior from this note?Was the patient a danger to others? Gravely disabled?
Slide1212THE LANGUAGE WE USEHere is the same note rewritten in behaviorally specific language: The patient interrupted the social worker leading the community meeting three times, and when asked to wait until the “Open Discussion” part of the meeting, he kicked at the empty chair in front of him. After group the patient came to the nursing station and, pointing his finger at the refrigerator, asked if he could have his morning snack. When told that the snack would be ready in 10 minutes, he went to the day room and sat silently, staring toward the nursing station. After 15 minutes, an aide reported that the patient was rubbing his genital region with his hand. He continued to ask questions at the nursing station throughout the morning, usually regarding the next smoke break, snack or meal.
Slide1313THE LANGUAGE WE USEHere are a few examples of behaviorally non-specific words/phrases and their behaviorally specific counterparts:
DON’T WRITE THISTHIS WOULD BE BETTER
Impulsive
Acts without anticipating consequences as exhibited by grabbing items from other patients’ hands.
Aggressive
Shoved other patients out of the cafeteria line so that he could be served first.
Postured Aggressively
Shook a closed fist in the therapist’s face.
Threatening
She said, “If you ask me another question I will slap you.”
Hostile
He shouted, “Go to Hell” when he was asked to join the therapy group.
+HI
Describe the ideation. Is it active or passive? Is it directed
at a particular person? Is it directed at an identifiable group of people? Is it accompanied by homicidal intent? Is there a specific plan? Opportunity? Means? Timing?
Slide1414THE LANGUAGE WE USE
DON’T WRITE THISTHIS WOULD BE BETTER+DTO
What specific behaviors constitute “+DTO”?
Labile
Describe the different mood states, how quickly they alternate, whether there are triggers for the alternations, etc.
Sullen
“When greeted the patient stared intently back at me. When asked how he felt, he said, ‘I hate it here.’”
Sexually Inappropriate
The patient began masturbating in the dayroom.
Disruptive
She frequently interrupted the group leader and other participants, shouting her thoughts and reactions.
Suicidal or +SI
Ideation? Passive or Active? Intent? Specific Plan? Means? Opportunity? Timing?
+DTS
What specific behaviors constitute “+DTS”?
+SIB
Describe the specific types of self-injurious behavior. What
were the medical consequences?
Slide1515THE LANGUAGE WE USE
DON’T WRITE THISTHIS WOULD BE BETTERDespondent
The patient said, “I feel there is no hope for me. There is nothing I can do to change my life.”
Psychotic
Appears preoccupied with listening to voices. Frequently shouts in response to what she hears.
Disorganized
In what specific ways is the patient
being “disorganized”? Example: “Patient smeared feces on the walls of his bathroom.”
+CAH
What are the voices commanding him to do? Is he able to resist obeying the commands?
Poor ADLs
Refuses to brush teeth. Has not showered X 2 days. Describe reasons for behaviors. E.g., are poor ADLS secondary to skill deficits, delusional beliefs, social phobia?
Paranoid
Describe the specific behaviors/statements which cause the writer
to describe the patient as “paranoid.”
Regressed
“Patient refused to put on clothing, and continued to sit, rocking back and forth, in the corner of his room.”
Slide1616THE LANGUAGE WE USE
DON’T SAY THISTHIS WOULD BE BETTERUnpredictable
In what specific ways has
the patient exhibited “unpredictable” behavior? E.g., “The patient walked up to the counter at the nursing station, and shoved the computer onto the floor.”
+Poor Coping Skills
Describe both the specific behaviors which lead to the inference that there are “poor coping skills,” as well as the circumstances in which these deficits have been observed.
+GD
What observable behaviors constitute “+GD”? Simply being unable to formulate and/or execute
a plan for self-care does not constitute being gravely disabled.
Blowing Up
What exactly did the patient do? For example, “He overturned the medication cart and punched a mental health worker in the mouth with a closed fist.”
Slide1717MEDICAL NECESSITY CRITERIA FOR ADMISSION--DIAGNOSISThere must be an included diagnosis. Here is a list of the families of diagnoses which are covered for inpatient services:(A) Pervasive Developmental Disorders (including Autistic Disorder)(B) Disruptive Behavior and Attention Deficit Disorders(C) Feeding and Eating Disorders of Infancy or Early Childhood(D) Tic Disorders(E) Elimination Disorders(F) Other Disorders of Infancy, Childhood, or Adolescence
Slide1818MEDICAL NECESSITY CRITERIA FOR ADMISSION--DIAGNOSIS(G) Cognitive Disorders (only Vascular Dementia with Delusions or Depressed Mood)(H) Substance-Induced Disorders (only with Psychotic, Mood or Anxiety Disorder)(I) Schizophrenia and Other Psychotic Disorders(J) Mood Disorders(K) Anxiety Disorders(L) Somatoform Disorders(M) Dissociative Disorders(N) Eating Disorders(O) Intermittent Explosive Disorder(P) Pyromania(Q) Adjustment Disorders(R) Personality Disorders (including Antisocial Personality Disorder)
Slide1919GUIDANCE & RECOMMENDATIONS—DIAGNOSISThe diagnosis used for audit purposes is the DIAGNOSIS ON THE DISCHARGE SUMMARYIf the admitting and discharge diagnoses are different, the medical record should include:The date on which the change was made A description of the clinical information which led to the change. “Clinical information” may include behavioral observation, interview findings, psychometric test
data, laboratory studies, imaging studies, responses to treatment, newly received information about the patient’s medical/psychiatric/psychological history, and so forth. This is especially important when a diagnosis changes from a covered to a non-covered one, or from a non-covered to a covered one.
Slide2020GUIDANCE & RECOMMENDATIONS—DIAGNOSISType 1 Example (Excluded to Included):Admitting Diagnosis: Dementia of the Alzheimer’s TypeDischarge Diagnosis: Psychotic Disorder NOSMedical record should include:Date on which the diagnosis was changedClinical data which led to the change. In this case, for example, the clinical data may have been the results of an MRI which revealed no diffuse cortical atrophy or other pathological findings.
Slide2121GUIDANCE & RECOMMENDATIONS—DIAGNOSISType 2 Example (Included to Excluded):Admitting Diagnosis: Psychotic Disorder NOSDischarge Diagnosis: Dementia of the Alzheimer’s Type
Medical record should include:Date on which the diagnosis was changedClinical data which led to the change. In this case, for example, the clinical data may have been one or more of the following:The results of an MRI which revealed diffuse cortical atrophy or other pathological findingsBehavioral observation that the patient had difficulty finding his room, even after several days in the hospitalNo recognition of the attending psychiatrist and other medical personnel with whom he worked on a daily basis
Slide2222GUIDANCE & RECOMMENDATIONS—DIAGNOSISIn the Type 2 Example on Slide 17, the day on which the hospital stay would have become non-reimbursable would have been the day on which the MRI results became available to the patient’s psychiatrist or psychologist.In the Type 2 case, the medical necessity determination hinges on the answer to the following question: “When should a reasonably astute clinician have become aware that the correct diagnosis was a non-covered one?”.
Slide2323GUIDANCE & RECOMMENDATIONS—DIAGNOSISThe way in which diagnoses are written is very important:Diagnoses which are followed by such words/phrases as “By History” or “Versus Diagnosis XXX,” or which are preceded by words such as “Provisional,” “Preliminary,” “Working,” or “Consider” do not meet medical necessity criteria.
Slide2424GUIDANCE AND RECOMMENDATIONS-DIAGNOSIS A “stand alone” Rule Out Diagnosis does not meet medical necessity criteria.Here is an actual example of what was written as a “Discharge Diagnosis”: Mood Disorder NOS, Rule Out Substance-Induced Mood Disorder, Rule Out Bipolar Disorder , Anxiety Disorder NOS, Rule Out Obsessive—Compulsive Disorder, Rule Out Panic Disorder with Agoraphobia, Rule Out Social Anxiety Disorder, Rule Out Generalized Anxiety Disorder, Rule Out Methamphetamine Abuse
Slide2525GUIDANCE & RECOMMENDATIONS—DIAGNOSISThe example on Slide 24 illustrates two important points:Eliminate competing diagnoses wherever possible. In this case, a urine drug screen and a carefully taken history could have eliminated or established Substance-Induced Mood Disorder and Methamphetamine Abuse.A thorough diagnostic interview, including a comprehensive mental status examination, should have made it possible to eliminate one or more of the following:Anxiety Disorder NOSObsessive-Compulsive DisorderPanic Disorder with AgoraphobiaSocial Anxiety DisorderGeneralized Anxiety Disorder
Slide2626GUIDANCE & RECOMMENDATIONS—DIAGNOSISDiagnoses must be supported by the symptoms and behaviors documented in the assessment.Here is an example of diagnoses which were not supported:A 45-year-old single female patient reported the onset of depressed mood six months prior to admission. Three months prior to admission the patient began consuming large amounts of alcohol daily. Mental status examination indicated patient’s memory was “intact” for immediate and recent memory.Alcohol-Induced Mood DisorderKorsakoff’s Syndrome
Slide2727GUIDANCE & RECOMMENDATIONS—DIAGNOSISHere is a second example of a diagnosis in need of clarification:Admitting Diagnosis: Psychotic Disorder NOS, Rule Out Methamphetamine-Induced Psychotic DisorderLaboratory Findings on Hospital Day #1: Urine Drug Screen Positive for Methamphetamine Discharge Diagnosis: Psychotic Disorder NOS
Slide2828GUIDANCE AND RECOMMENDATIONS-DIAGNOSIS Implications of Failure to Assign Correct Diagnosis:Patient received no inpatient substance use disorder counselingDischarge planning did not center around dual diagnosis treatment facilitiesThe aftercare plan did not include substance use disorder services
Slide2929GUIDANCE & RECOMMENDATIONS—DIAGNOSISThe following diagnoses/diagnostic groups are among those which do NOT qualify for Medi-Cal reimbursement for acute psychiatric inpatient hospital services: a. Mental Retardation b
. Learning Disorders c. Motor Skills Disorder d. Communication Disorders e. Delirium f. Dementia (except Vascular Dementia with Delusions or Depressed Mood) g. Amnestic Disorders h. Cognitive Disorder NOS
Slide3030GUIDANCE & RECOMMENDATIONS—DIAGNOSISi. Mental Disorders Due to a General Medical Conditionj. Substance-Induced Disorders (except Substance- Induced Psychotic, Mood or Anxiety Disorder)k. Factitious Disordersl. Sexual and Gender Identity Disordersm. Sleep Disordersn. Impulse Control Disorders Not Elsewhere Classified (except Intermittent Explosive Disorder and Pyromania)o. Other Conditions That May Be a Focus of Clinical Attention (V Codes)
Slide3131GUIDANCE & RECOMMENDATIONS—DIAGNOSISDiagnoses—especially the one which is used to establish medical necessity—must be clearly and legibly written or typed on the Discharge Summary.Diagnoses must be written out and should preferably be accompanied by the appropriate ICD code. Acronyms (e.g., PDNOS) are NOT acceptable.
Slide3232GUIDANCE AND RECOMMENDATIONS-DIAGNOSISA beneficiary may have both a covered and a non-covered diagnosis. However, a qualifying impairment resulting from the covered diagnosis must be the primary focus of the treatment provided.
Slide3333FREQUENTLY ASKED QUESTIONS: ADMISSION1. What determines the actual date and time of admission? ANSWER: Admission is timed from the moment when the beneficiary is physically brought onto the inpatient unit and begins to receive care, which is usually documented in a nursing progress note or assessment. For purposes of Medi- Cal reimbursement, the admission is NOT considered to have occurred on the date and ate the time of the physician’s admitting order.2. Is Autistic Disorder a covered diagnosis for inpatient services?
ANSWER: Yes, it is covered for inpatient services but not for outpatient services.
Slide3434FREQUENTLY ASKED QUESTIONS: ADMISSION3. What about Antisocial Personality Disorder? ANSWER: Yes, it is covered for inpatient services but not for outpatient services.4. Is Impulse Control Disorder NOS covered for inpatient services? ANSWER: It is not covered for inpatient services, but it is covered for outpatient services.
Slide35IMPROVING INPATIENT DOCUMENTATIONREASONS FOR RECOUPMENT—INPATIENT HOSPITAL SERVICESAdmission—Reason #22Documentation does not establish that the beneficiary had an included diagnosis.Documentation does not establish that the beneficiary could not have been safely treated at a lower level of care, except that a beneficiary who can be safely treated with crisis residential treatment services or psychiatric health facility services shall be considered to have met this criterion.
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Slide36IMPROVING INPATIENT DOCUMENTATIONDocumentation does not establish that the beneficiary, as a result of an included diagnosis, required admission to an acute psychiatric inpatient hospital for one of the following reasons:Presence of symptoms or behaviors that represent a current danger to self or others, or significant property destructionPresence of symptoms or behaviors that prevent the beneficiary from providing for, or utilizing, food, clothing or shelter36
Slide37IMPROVING INPATIENT DOCUMENTATIONPresence of symptoms or behaviors that present a severe risk to the beneficiary’s physical healthPresence of symptoms or behaviors that represent a recent, significant deterioration in ability to functionPresence of symptoms or behaviors that require further psychiatric evaluation, medication treatment, or other treatment that could reasonably be provided only if the patient were hospitalized37
Slide3838MEDICAL NECESSITY CRITERIA—LEVEL OF CAREMEDICAL NECESSITY CRITERIA—LEVEL OF CARE REQUIREMENTSection 1820.205(a)(2)(A) of CCR Title 9 states that in order to meet medical necessity criteria for admission to an acute psychiatric inpatient hospital, documentation must establish that the beneficiary cannot be safely treated at a lower level of care, except that a beneficiary who can be safely treated with crisis residential treatment services or psychiatric health facility services for an acute psychiatric episode shall be considered to have met this criterion.
Slide3939MEDICAL NECESSITY CRITERIA—LEVEL OF CAREThis criterion is based upon Sections 5325.1 and 5325.1(a) of the Welfare and Institutions Code, which state:It is the intent of the Legislature that persons with mental illness shall have rights including, but not limited to, the following:(a) A right to treatment services which promote the potential of the person to function independently. Treatment should be provided in ways that are least restrictive of the personal liberty of the individual.
Slide4040MEDICAL NECESSITY CRITERIA—LEVEL OF CAREIn making level of care assessments and determinations, it is essential to understand not only the patient’s treatment needs but the range of services available at the various levels of care as well as the levels of tolerance for certain types of behavior. Here are some examples:The most common types of step-down facilities are crisis residential treatment facilities and adult residential treatment facilities. These facilities are not locked facilities, so the patient’s ability to be safely treated in an open setting needs to be determined.
Oral PRN medication is available at crisis and adult residential treatment facilities, but intramuscular PRN medication is generally not.
Slide4141MEDICAL NECESSITY CRITERIA—LEVEL OF CAREResidential treatment facilities do provide limited prompting and assistance with activities of daily living, but they are not able to handle the needs of total care patients.Residential treatment facilities are not able to accept patients whose behavior is grossly disorganized or disruptive of the treatment milieu (e.g., fecal smearing, refusal to remain clothed, sexual aggression toward others, prolonged screaming or yelling).
Slide4242IMPROVING INPATIENT DOCUMENTATIONDocumentation Example:Patient went AWOL from her residential placement after being “influenced by a friend.” The patient was apprehended by police after she ran into traffic. She “reported SI if she had to return to her former placement.” Mental Status Examination: Sixteen-year-old Hispanic female in no acute distress. Fair eye contact. Cooperative with interview, answers questions appropriately but says “I don’t know” to many questions. Mood: Depressed. Suicidal Ideation: Yes, passive. Suicidal Intent: Yes, if she has to return to her former placement. Suicidal Plan: Denies active plan at this time.
Slide4343IMPROVING INPATIENT DOCUMENTATIONHospital Plan: Patent is appropriate for inpatient level of care for close monitoring for safety, continued adjustment in medications to target depression, and for coordination of outpatient care for continued control of symptoms after discharge.Could this patient have been evaluated and treated at a lower level of care?
Slide4444MEDICAL NECESSITY CRITERIA—INDICATORS FOR ADMISSIONThe impairment criteria for admission to an acute psychiatric inpatient hospital are provided in CCR Title 9 Sections 1820.205(a)(2)(B)1.a through 1820.205(a)(2)(B)1.d. and 1820.205(a)(2)(B)2.a. through 1820.205(a)(2)(B)2.c. Here are the criteria:Presence of symptoms or behaviors that represent a current danger to self or others, or of significant property destructionPresence of symptoms or behaviors that prevent the beneficiary from providing for, or utilizing, food, clothing or shelterPresence of symptoms or behaviors that present a severe risk to the beneficiary’s physical health
Slide4545MEDICAL NECESSITY CRITERIA—INDICATORS FOR ADMISSIONPresence of symptoms or behaviors that represent a recent, significant deterioration in ability to functionNeed for psychiatric evaluation, medication treatment, or other treatment which can reasonably be provided only if the beneficiary is in a psychiatric inpatient hospitalREMEMBER: The qualifying impairment must be the direct result of the included diagnosis.
Slide4646GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR ADMISSION/IMPAIRMENT CRITERIAGENERAL POINT:In those hospitals where patients are admitted from a crisis stabilization unit (CSU) or a psychiatric emergency service (PES), it is imperative that decisions regarding admission be based upon the beneficiary’s clinical condition just prior to admission—and not upon the behaviors and symptoms which the beneficiary was exhibiting at the time of entry into the CSU or PES.
Slide4747GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR ADMISSION/IMPAIRMENT CRITERIA1. CURRENT Danger to Self (DTS), Danger to Others (DTO), or Danger to Property (DTP). In order to meet one of these three impairment criteria, there must be documentation of suicidal, homicidal or property destruction ideation, together with either documented intent or a specific plan. (a) If the beneficiary is experiencing command auditory hallucinations to harm self or others, or to destroy property, this fact should be documented together with an assessment of the beneficiary’s ability to resist obeying the commands. In the absence of such documented assessment, the presence of command auditory hallucinations alone does not establish that the beneficiary is a DTS, DTO or DTP.
Slide4848GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR ADMISSION/IMPAIRMENT CRITERIA (b) It sometimes occurs that a beneficiary expresses suicidal/homicidal/property destruction ideation, intent and/or specific plan in a way which is purely conditional—e.g., “I feel safe here, but if I were discharged, I would kill myself by overdosing on my medication.” In such cases, in order to establish medical necessity for admission (or for continued stay services), there must be a documented assessment of how the beneficiary would react to/feel about being discharged to a residential treatment facility where s/he would have 24-hour access to staff.
Slide4949MEDICAL NECESSITY CRITERIA—INDICATORS FOR ADMISSION/IMPAIRMENT CRITERIAMany times beneficiaries make these conditional statements because :they fear being discharged to a place where they would not have adequate support and professional attentionthey do not have access to food and shelter or the means to purchase them. If the assessment reveals that the beneficiary would feel safe in a residential treatment facility, then admission (or continued stay services) would not be appropriate.
Slide5050GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR ADMISSION/IMPAIRMENT CRITERIA(c) Although documentation of general risk factors does not establish medical necessity, such documentation may constitute supplementary information which is useful in making treatment and discharge planning decisions.
Slide5151GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR ADMISSION/IMPAIRMENT CRITERIA2. Beneficiary is unable to provide for or utilize food, clothing or shelter.(a) The correct standard to apply when evaluating for this criterion is whether the beneficiary is able to utilize (rather than formulate / carry out a plan for obtaining) the food, clothing and shelter which is provided. The reason this is the correct standard is that in the step-down levels of care to which the beneficiary could be diverted or discharged, food, clothing and shelter are provided.
Slide5252GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR ADMISSION/IMPAIRMENT CRITERIA(b) Some of the symptoms/behaviors which meet this impairment criterion are: (1) Refusing to eat and/or take liquids to an extent which jeopardizes the beneficiary’s health status; (2) Refusing to remain clothed; (3) Engaging in sexual behavior in public areas; and (4) Behaving in so grossly disorganized a manner as to be unmanageable at a lower level of care (e.g.,
smearing feces, urinating in public areas).
Slide5353GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR ADMISSION/IMPAIRMENT CRITERIA3. Beneficiary has symptoms/behaviors that present a severe risk to his/her health.(a) The essential element is that the symptoms / behaviors which present a severe risk to the beneficiary’s physical health must be a direct result of the covered diagnosis. In order to qualify, the behaviors creating the risk cannot be the result of a deliberate, rational decision reached by the beneficiary.
Slide5454GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR ADMISSION/IMPAIRMENT CRITERIA(b) The most frequently encountered example of this type of impairment would be refusal to eat secondary to Anorexia Nervosa. A less common, example would be refusal to eat secondary to delusional beliefs (e.g., that food is poisoned or that spiritual salvation can only be achieved by depriving the physical body of sustenance). (c) A
patient’s saying, “I am going to drink myself to death” does not meet this criterion because the proclaimed behavior does not represent a current or even short-range danger to self.
Slide5555GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR ADMISSION/IMPAIRMENT CRITERIA4. Beneficiary has symptoms/behaviors that represent a recent, significant deterioration in ability to function.(a) The level of care criterion still applies here: Even if there is a “recent, significant deterioration in ability to function,” when the beneficiary could be evaluated and treated at a lower level of care admission (and continued stay services) may not be reimbursable. (b) Documentation should include a description of the patient’s previous level of functioning as well as an explanation of why the patient could not be safely and
effectively treated at a lower level of care.
Slide5656GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR ADMISSION/IMPAIRMENT CRITERIA (c) If there is a medical (as opposed to psychiatric) basis for the recent, significant deterioration in ability to function, the hospital stay would not be reimbursable.
Slide5757GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR ADMISSION/IMPAIRMENT CRITERIA5. Beneficiary requires further psychiatric evaluation. The level of care criterion applies here: (a) If the evaluation which the beneficiary requires could be provided at a lower level of care, the admission is not reimbursable.(b) If the justification for the admission is based upon
convenience to the beneficiary (or the staff), the admission is not reimbursable.
Slide5858GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR ADMISSION/IMPAIRMENT CRITERIA6. Beneficiary requires medication treatment. As before, the level of care criterion applies here:
If the medication treatment or medication adjustment which the beneficiary requires could be performed at a lower level of care (such as an outpatient clinic), then the admission is not reimbursable.
Slide5959GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR ADMISSION/IMPAIRMENT CRITERIAIf, however, a patient has experienced a life threatening reaction to a medication in the past (e.g., agranulocytosis or neuroleptic malignant syndrome), and there is a clinically compelling reason why the patient needs to be restarted on the same medication, this could constitute a valid reason for restarting the medication in an inpatient hospital setting.
Slide6060GUIDANCE AND RECOMMENDATIONS—INDICATORS FOR ADMISSION/IMPAIRMENT CRITERIA7. Beneficiary requires other treatment that can reasonably be provided only if the patient is hospitalized.(a) If the beneficiary does not meet any of the preceding impairment criteria, it is unlikely that s/he will meet this one because nearly all treatments, including electroconvulsive treatment, may be safely provided on an outpatient basis.(b) Convenience of the staff or beneficiary does not satisfy this criterion.
Slide6161FOCUS OF TREATMENT REQUIREMENTThe primary focus of the treatment must be to address the qualifying indicator which establishes medical necessity for admission.Example: If a patient is admitted with a diagnosis of Alcohol-Induced Mood Disorder and is determined to be a Danger to Self, the focus of the treatment must be to address the dysthymia and to reduce the impairments which constitute the “Danger to Self”—e.g., suicidal ideation and either intent or a specific plan. The primary (or only) focus of the treatment may NOT be on preventing withdrawal symptoms—although it may be a secondary focus of treatment.
Slide6262EFFICACY REQUIREMENTThe efficacy requirement means that the treatment planned for and provided to the beneficiary must have a reasonable likelihood of reducing the impairment resulting from the qualifying indicator for admission. The following are examples of treatments which would not meet the efficacy requirement:Occupational therapy focusing on arts and crafts and the development of fine motor skills as the only psychosocial treatment for a patient admitted with Attention-Deficit/Hyperactivity Disorder.
Slide6363EFFICACY REQUIREMENTAntipsychotic medication prescribed as the primary treatment for a patient with Intermittent Explosive Disorder in the absence of hallucinations, delusions or thought disorder.
Slide6464IMPROVING INPATIENT DOCUMENTATIONFREQUENTLY ASKED QUESTIONS/POINTS OF CONFUSION1. Is it permissible to use forms which consist entirely of check boxes for staff to fill in? ANSWER: No. If check boxes are used, there must be some narrative statement by the physician/nurse which confirms and elaborates upon the checked box(es). Many times the labels attached to check boxes are not behaviorally specific and do not communicate any precise meaning. For example, a check box labeled “Suicidal” does not convey specific information. If the box is checked, the reader does not know which of the following elements is present: ideation, intent, plan, means, opportunity. Similarly, a check box labeled “DTO” does not communicate the way(s) in which the patient is a danger to others.
Slide6565IMPROVING INPATIENT DOCUMENTATION2. Does there have to be a physician’s note for every claimed hospital day? ANSWER: Although this is a highly desirable practice,
Medi- Cal regulations do not require that there be a physician’s note for each hospital day (or, for that matter, any physician’s notes). What is required is that there be documentation which establishes medical necessity for each claimed day.
Slide6666MEDICAL NECESSITY CRITERIA—INDICATIONS FOR CONTINUED STAY SERVICESThe impairment criteria for continued stay services in an acute psychiatric inpatient hospital are in CCR Title 9 Sections 1820.205(b)(1) through 1820.205(b)(4):
Presence of symptoms or behaviors that represent a current danger to self or others, or of significant property damagePresence of symptoms or behaviors that prevent the beneficiary from providing for, or utilizing, food, clothing or shelterPresence of symptoms or behaviors that present a severe risk to the beneficiary’s physical health.
Slide6767IMPROVING INPATIENT DOCUMENTATIONPresence of symptoms or behaviors that represent a recent, significant deterioration in ability to functionNeed for further evaluation, medication treatment, or other treatment that can reasonably be provided only if the beneficiary is in a psychiatric inpatient hospitalPresence of one of the following:A serious adverse reaction to medicationsProcedures or therapies requiring continued hospitalizationThe presence of new indications that meet medical necessity criteriaThe need for continued medical evaluation
Treatment that can only be provided if the beneficiary remains in a hospital
Slide6868GUIDANCE AND RECOMMENDATIONS—CONTINUED STAY SERVICES1. Documentation on continued stay service days should reflect symptoms and behaviors exhibited on that day and not on previous days, including the day of admission or days on which the patient was in a CSU or PES.
2. Documentation should reflect the beneficiary’s actual progress. Symptomatic improvement is almost always gradual rather than sudden.
Slide6969IMPROVING INPATIENT DOCUMENTATIONWhen a beneficiary is admitted following a high lethality suicide attempt, a serious attempt to harm another, or a serious attempt to destroy property, it is understandable that the hospital professional staff may be reluctant to discharge the beneficiary as soon as the denial of symptoms has begun. In these cases, it is appropriate to grant one or more stabilization days during which the staff may continue to assess the beneficiary in a protected setting and determine whether this improvement is genuine or only apparent. Stabilization days should be used only following a high lethality event and then very cautiously.
Slide7070IMPROVING INPATIENT DOCUMENTATION4. When documentation from different disciplines shows a pattern of inconsistency or contradiction, the credibility of the entire medical record suffers. In general, greater weight is accorded documentation which is more behaviorally specific.
Slide7171IMPROVING INPATIENT DOCUMENTATIONDocumentation Example:Patient was observed to be isolative, withdrawn, pacing most of the time in the hallways. Patient was observed talking to himself and seeing people. Patient was agreeable with starting psychotropic medication and he signed the consent for medication. What do you think of this note?
Slide7272IMPROVING INPATIENT DOCUMENTATIONDocumentation Example:“Patient is very irritable, guarded, paranoid, labile, intrusive, very short-tempered, brusque during this interview and becomes guarded, irritable and demanding during this evaluation. States he has not been able to sleep in spite of Seroquel, and agrees to a dosage increase. Agrees to the addition of Depakote for his mood stabilization. Patient continues to be depressed, dysphoric, unable to contract for safety. High risk of explosive and self-destructive behavior; requires inpatient treatment and stabilization.”Comments?
Slide7373FREQUENTLY ASKED QUESTIONS1. Does a history of previous psychiatric hospitalizations affect the likelihood that the beneficiary’s current hospital stay will be Medi- Cal reimbursable?ANSWER: In general, medical necessity determinations are based upon an evaluation of the patient’s current symptoms and behavior. However, if a patient has a history of multiple hospitalizations resulting from high-lethality suicide or homicide attempts, these historical events may be taken into account indirectly if circumstances or triggers similar to those which were associated with previous incidents are present during the current admission.
Slide7474IMPROVING INPATIENT DOCUMENTATION2. Do chart notes written by medical students “count” in making medical necessity determinations?ANSWER: Medical necessity determinations should be based upon documentation written by licensed, registered or waivered mental health professionals. However, documentation written by non-licensed individuals (e.g., medical students, interns, or, in some cases, residents) may be used to provide confirmation of information contained in progress notes written by licensed, registered or waivered individuals.
Slide75IMPROVING INPATIENT DOCUMENTATIONREASONS FOR RECOUPMENT—INPATIENT HOSPITAL SERVICESContinued Stay Services—Reason #23Documentation does not establish the continued presence of an included diagnosisDocumentation does not establish that the beneficiary could not have been safely treated at a lower level of care, except that a beneficiary who can be safely treated with crisis residential treatment services or psychiatric health facility services shall be considered to have met this criterion
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Slide76IMPROVING INPATIENT DOCUMENTATIONDocumentation does not establish that, as a result of an included mental disorder, the beneficiary required continued stay services for one of the following reasons:Presence of symptoms or behaviors that represent a current danger to self or others, or significant property destructionPresence of symptoms or behaviors that prevent the beneficiary from providing for, or utilizing, food, clothing or shelterPresence of symptoms or behaviors that present a severe risk to the beneficiary’s physical healthPresence of symptoms or behaviors that represent a recent, significant deterioration in ability to function76
Slide77IMPROVING INPATIENT DOCUMENTATIONPresence of symptoms or behaviors that require further psychiatric evaluation, medication treatment, or other treatment that can reasonably be provided only if the patient is hospitalizedPresence of a serious adverse reaction to medications, procedures or therapies requiring continued hospitalizationPresence of new indications that meet medical necessity criteria specified for admissionPresence of symptoms or behaviors that require continued medical evaluation or treatment that can only be provided if the beneficiary remains in an acute psychiatric inpatient hospital77
Slide7878IMPROVING INPATIENT DOCUMENTATIONREQUIREMENTS FOR PLANS OF CAREThe required elements for acute psychiatric inpatient hospital plans of care are to be found in two different sources: The Code of Federal Regulations, Title 42, Section 456.180 andThe contract between DHCS and the MHPs, Exhibit A, Attachment 1.These requirements are as follows:
Code of Federal Regulations, Title 42, Section 456.180(a) Before admission to a mental hospital or before authorization for payment the attending physician or staff physician must establish a written plan of care for each applicant or beneficiary.
Slide7979IMPROVING INPATIENT DOCUMENTATION(b) The plan of care must include– (1) Diagnoses, symptoms, complaints, and complications indicating the need for admission; (2) A description of the functional level of the individual; (3) Objectives; (4) Any orders for— (i) Medications; (ii) Treatments; (iii) Restorative and rehabilitative services;
(iv) Activities; (v) Therapies; (vi) Social services; (vii) Diet; and (viii) Special procedures recommended for the health and safety of the patient;
Slide8080IMPROVING INPATIENT DOCUMENTATION(5) Plans for continuing care, including review and modification to the plan of care; and(6) Plans for discharge.The attending or staff physician and other personnel involved in the beneficiary’s care must review each
plan of care at least every 90 days.
Slide8181IMPROVING INPATIENT DOCUMENTATIONContract Between DHCS and the MHPs(1) The Contractor shall ensure that Client Plans: (a) Have specific observable and/or quantifiable goals/treatment objectives related to the beneficiary’s mental health needs and functional impairments as a result of the mental health diagnosis; (b) Identify the proposed type(s) of intervention/modality including a detailed description of the intervention to be provided; (c) Have a proposed frequency and duration of intervention(s); (d) Have interventions that focus and address the identified functional impairments as a result of the mental disorder; have interventions that are consistent with the client plan goal;
(e) Be consistent with the qualifying diagnoses; (f) [Not Applicable to inpatient client plans.] (g) Include documentation of the beneficiary’s participation in and agreement with the client plan.
Slide8282GUIDANCE AND RECOMMENDATIONS—PLANS OF CARE1. For audit purposes, the plan of care is considered to consist of the interdisciplinary (or master) treatment plan PLUS the physician’s admitting order sheet.2. CFR
Section 456.180(a) requires that “the attending physician or staff physician must establish a written plan of care . . .” The physician indicates his/her establishment of the plan by signing the plan of care.3. The plan of care must be completed for all hospital stays which are greater than or equal to 72 hours in length.4. The client plan may NOT be imbedded in a progress note, but must be a separate document which is labeled “Client Plan” or “Master Treatment Plan” or “Interdisciplinary Treatment Plan” or something similar.
Slide8383IMPROVING INPATIENT DOCUMENTATIONFREQUENTLY ASKED QUESTIONS/POINTS OF CONFUSION1. May the physician’s signature be on a progress note which refers to the client plan? ANSWER: No. The physician’s signature establishing the plan of care must be on the plan itself. 2. What if there is a signature on the client plan but it is illegible?
ANSWER: If the signature can be verified through a signature sheet it may be counted.
Slide8484IMPROVING INPATIENT DOCUMENTATIONFREQUENTLY ASKED QUESTIONS/POINTS OF CONFUSIONIs it permissible to use subjective rating scales to quantify patient status/patient goals? For example, is it permissible to have the patient rate his/her mood on a scale from 1 to 10?
ANSWER: Yes. Subjective rating scales are permissible. These scales work best when the endpoints, as well as one or two “anchor points” between the endpoints of the scale, are defined in specific terms in collaboration with the patient.Should progress notes refer to the goals described in the plan of care? ANSWER: Yes. It is important that each progress note address those patient goals which are within the scope of practice of the person writing the note.
Slide8585IMPROVING INPATIENT DOCUMENTATIONInterdisciplinary Treatment Plan ExampleProblem #1: DTS AEB pt. wants P.D. to shoot her.Problem #2: Alteration in cardiac output AEB pt. Hx of HTN.Short-Term Goal #1 for Problem #1: Pt. will not be a risk to herself while hospitalized. Intervention: Monitor pt. q 15 min, provide safe environment.Short-Term Goal #2 for Problem #1:
Pt. will attend and participate in daily Tx team prior to D/C. Interventions: Build rapport and develop level of trust on a daily basis.Comments?
Slide86IMPROVING INPATIENT DOCUMENTATIONClient Plan—Reason #27The client plan was not signed by a physician. Other—Reason #28A hospital day was claimed and paid (1) on which the beneficiary was not a patient in the hospital, or (2) for the day of discharge, neither of which is reimbursable.
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Slide8787REQUIREMENTS FOR ADMINISTRATIVE DAY SERVICES
The requirements for administrative day services are located in two places in Title 9 of the California Code of Regulations: Section 1820.220(j)(5) (Point of Authorization) Section 1820.230(d)(2) (Utilization Review Committee). The contents of these two sections are the same. The following is from Section 1820.230(d)(2):(2) Requests for MHP payment authorization for administrative day services shall be approved by the hospital’s Utilization Review Committee when both of the following conditions are met:
Slide8888REQUIREMENTS FOR ADMINISTRATIVE DAY SERVICES(A) During the hospital stay, a beneficiary previously had met medical necessity
criteria for acute psychiatric inpatient hospital services; (B) There is no appropriate, non-acute residential treatment facility within a reasonable geographic area and the hospital documents contacts with a minimum of five appropriate, non- acute residential treatment facilities per week for placement of the beneficiary subject to the following requirements: (1) The MHP or its designee can waive the requirement of five contacts per week if there are fewer than five appropriate, non-acute residential treatment facilities available as placement options for the beneficiary. In no case shall there be less than one contact per week.
Slide8989REQUIREMENTS FOR ADMINISTRATIVE DAY SERVICES(2) The lack of placement options at appropriate, residential treatment facilities and the contacts made at appropriate treatment facilities shall be documented to include but not be limited to: a. The status of the placement option. b. Date of the contact. c. Signature of the person making the
contact.
Slide9090GUIDANCE AND RECOMMENDATIONS—ADMINISTRATIVE DAY SERVICES1. “Non-acute residential treatment facilities” means facilities at which mental health treatment is provided to all beneficiaries for a significant period of time Monday through Friday of each week.
If a facility transports beneficiaries to treatment at an off- site location, that facility does not qualify as a residential treatment facility. Just how many minutes per day qualify as “a significant period of time” is up to the MHP. Non-augmented or regular board and care facilities do NOT qualify as “residential treatment facilities.”
Slide9191GUIDANCE AND RECOMMENDATIONS-ADMINISTRATIVE DAY SERVICES Augmented board and care facilities may qualify, depending upon the type, duration and frequency of services provided to beneficiaries. Case management does not count as “treatment” for purposes of this definition.
For children and adolescents, the definition of “non- acute residential treatment facility” usually consists of a designation by the MHP in its Implementation Plan of certain RCL levels.
Slide9292GUIDANCE AND RECOMMENDATIONS—ADMINISTRATIVE DAY SERVICES2. Waivers of the five-contact-per-week requirement by Point of Authorization/MHP staff must be in writing, and should be made part of the Utilization Review file for each beneficiary to whom the waiver applies.
There must be documentation which meets all administrative day requirements on the first day for which administrative day services reimbursement is granted. This date is designated as Day #1. Weeks should then be counted off as follows: Week #1 = Day #1 through Day #7; Week #2 = Day #8 through Day #14; Week #3 = Day #15 through Day #21, and so on.
Slide9393GUIDANCE AND RECOMMENDATIONS—ADMINISTRATIVE DAY SERVICES For each week, the number of contacts which meet all requirements should be summed and multiplied by 1.4. This product (# of days meeting requirements X 1.4) yields the number of reimbursable days in that particular week.
If acute days are interspersed between administrative days, the marking off of weeks should begin when administrative days resume. The rule of multiplying the number of qualifying contacts X 1.4 days works for “weeks” with fewer than seven days.
Slide9494GUIDANCE AND RECOMMENDATIONS—ADMINISTRATIVE DAY SERVICES“The status of the placement option” means a definite status—e.g., “patient accepted, bed will be available on September 2, 2010,” “patient accepted, is second on waiting list,” “patient rejected for admission.” The following are not considered to constitute a “status of the placement option”: “Packet FAXed,” “Left message,” “Spoke with _________, who said that packet is under review,” “Need documentation of TB skin test,” “Need more recent laboratory values,” “Patient may be acceptable; packet still under review.”
Slide9595GUIDANCE AND RECOMMENDATIONS—ADMINISTRATIVE DAY SERVICES5. When a patient who has been on administrative days is discharged home, or back to the facility from which he/she was admitted, the medical record must be examined to determine whether this abrupt change in the discharge plan was foreseeable. In other words, if the hospital was, in good faith, searching for a placement to which it fully intended to discharge the patient, but unforeseeable events outside of the hospital’s control operated to abort its discharge plan, then credit may be given for those administrative days which meet Title 9 criteria.
Slide9696FREQUENTLY ASKED QUESTIONS/POINTS OF CONFUSION
1. May administrative days be claimed when the hospital is waiting for an LPS conservatorship to be approved but is not actually contacting potential placements? ANSWER: No.2. If the first contact with a potential placement is documented on administrative day #3, may that contact be “counted” for administrative days #1 and #2? ANSWER: No. There must be at least one documented placement contact which meets all requirements on the first administrative day for which reimbursement is approved.
Slide9797IMPROVING INPATIENT DOCUMENTATION3. If a hospital deals with corporate entities which control multiple non-acute residential treatment facilities, does one call to a corporate entity which controls five facilities count as the five contacts for a one-week period? ANSWER: No. If, for example, there are three corporate entities which control all of the non-acute residential facilities within a reasonable geographic area, and those entities control five, three, and seven facilities, respectively, then the hospital is expected to contact all three. Although calling one corporate entity may reach five or more potential placements, the hospital in making that one call has not exceeded the required five contacts per week. There is no acceptable justification for not calling the other two corporate entities.
Slide9898IMPROVING INPATIENT DOCUMENTATIONAdministrative Day Services—Reason #24Documentation does not establish that the beneficiary previously met medical necessity for acute psychiatric inpatient hospital services during the current hospital stay.Administrative Day Services—Reason #25Documentation does not establish that there were contacts with a minimum of five (5) appropriate, non-acute residential treatment facilities per week for placement of the beneficiary which included (1) the status of the placement option, (2) the date of the contact, and (3) the signature of the person making the contact.
Slide99IMPROVING INPATIENT DOCUMENTATIONTwo Reminders Regarding Interpreter ServicesWhen a patient whose preferred language is other than English is admitted to an inpatient unit, the hospital must make interpreter services available to the patient so that he or she can communicate with treatment staff. These interpreter services may be provided by staff who are fluent in the patient’s preferred language, or by an interpreter service via telephone. Family members should not be asked to act as interpreters unless the patient specifically requests this and refuses other options for interpreter services. 99
Slide100IMPROVING INPATIENT DOCUMENTATIONPatients whose preferred language is other than English must also be provided with interpreter services during assessments, treatment planning meetings, treatment team meetings, and individual and group treatment sessions. These interpreter services may be provided by staff fluent in the patient’s preferred language or by interpreters who are physically present on the inpatient unit. The fact that a patient’s preferred language is other than English should not prevent him or her from receiving the full benefit of the treatment program which is offered to English speaking patients.100
Slide101101IMPROVING INPATIENT DOCUMENTATIONEXAMPLES OF DOCUMENTATION DEFICIENCIES ANDSOME RECOMMENDATIONSThe most frequent reasons for disallowance—both for admission and for continued stay services—are failure to
establish that (1) the patient could not have been treated at a lower level of care, and (2) the patient met impairment criteria for admission or continued stay services. Here are some examples, together with additional suggestions: a. The symptoms/behaviors for the day of admission are actually those which characterized the beneficiary during his/her stay in the CSU or PES, rather than upon the actual day of admission.
Slide102102IMPROVING INPATIENT DOCUMENTATIONb. The symptoms/behaviors for continued stay service days are actually those which were observed on the day of admission but which were repeated in documentation for subsequent hospital days by staff from one discipline, even though the
documentation by other disciplines contradicts it. c. Documentation does not contain elements required to establish impairment. For example:Symptom description is limited to “+SI, AH/VH, CAH, disorganized, unpredictable.” There is no clarification as to whether the suicidal ideation is active or passive, no description of the content of the ideation, no documented assessment of suicidal intent, no assessment as to the presence of a plan, no discussion of the availability of means/opportunity, and no assessment of the nature of the command auditory hallucinations or the patients ability to resist obeying them.
Slide103103IMPROVING INPATIENT DOCUMENTATION ii. The documentation states that the patient is “at risk” for self-harm, harm to others, etc., but no basis for this type of assertion is p
rovided. iii. The patient is said to be “GD, unable to formulate/carry out a plan for self-care.” As noted previously, the correct standard to apply in determining grave disability is whether the patient is able to avail himself/herself of the food, clothing and shelter which could be provided at a lower level of care.
Slide104104IMPROVING INPATIENT DOCUMENTATIONiv. No assessment of vegetative signs.v. Inadequate assessment of characteristics of sleep, including sleep pattern. For example, the presence of early morning awakening might suggest the presence of melancholia, which in turn might affect the choice of an antidepressant. vi. No assessment of stressors antecedent to symptom onset.
vii. No assessment of resource limitations which might exacerbate the impact of stressors on the severity of depression.
Slide105105IMPROVING INPATIENT DOCUMENTATIONd. There is little or no exploration of the patient’s symptomatology. For example, with beneficiaries complaining of depression, which is the most frequent cause for hospitalization, one or more of the following is often observed:i. No assessment of the quality of the beneficiary’s affective state: Is the depression experienced as a poignant feeling, or is there a generalized flattening of emotionality?ii. No assessment of the patient’s cognitive status. For example, is there significant cognitive “narrowing,” or either/or thinking. The presence of cognitive narrowing is an important indicator that psychotherapy may be indicated (especially cognitive restructuring) in addition to other treatment modalities.
Slide106106IMPROVING INPATIENT DOCUMENTATIONe. There is often no apparent relationship between the beneficiary’s symptomatology and the choice of psychopharmacological agent. With increasing frequency there is a tendency for beneficiaries to receive treatment with drugs from several classes: an antidepressant, an antipsychotic, an anxiolytic, and a mood stabilizer.f. There is no systematic assessment and documentation of the beneficiary’s ability to be managed at a lower level of care. Inpatient charts frequently state that the “patient cannot be managed at a lower level of care,” but fail to explain—in behaviorally specific terms—why this is the case.
Slide107107IMPROVING INPATIENT DOCUMENTATIONTreatment PlansPlans of care frequently exhibit the following deficiencies:Treatment
goals focus exclusively on keeping the beneficiarysafe (or keeping him/her from harming others) rather than upon keeping him/her safe AND treating the biopsychosocial problems which caused the beneficiary to come to the hospital in the first place.
Slide108108IMPROVING INPATIENT DOCUMENTATIONb. Treatment goals tend to be “all or nothing.” For example, a goal for a “suicidal” beneficiary might be: “Patient will not engage in self-harming behavior during the hospitalization.” Or: “Patient will not have any suicidal ideation at the time of discharge.” An example of a frequently seen goal for a psychotic patient is, “Patient will not report auditory hallucinations at the time of discharge.” For most psychotic beneficiaries, this is not a realistic goal.Reducing the frequency and intensity to a tolerable level might be realistic, however, as would equipping the beneficiary with coping skills to allow him/her to live with chronic psychotic symptoms.
Goals must be behaviorally specific and must be quantified. As mentioned previously, many symptoms can be quantified through self-report with the aid of a simple scale with clearly defined anchor points.
Slide109109IMPROVING INPATIENT DOCUMENTATIONc. Interventions tend to be standardized rather than customized for the individual beneficiary. Not only should the interventions themselves be tailored to the needs and characteristics of a particular beneficiary, but the manner of approach to the patient should also be customized and spelled out in the plan of care.d. Most interventions tend to be milieu-based rather than being actions which are carried out within the context of a therapeutic relationship—whether group or individual.
Slide110110IMPROVING INPATIENT DOCUMENTATIONOne of the most significant deficiencies found frequently in inpatient charts is the absence of case conceptualization. We will illustrate this deficiency with a clinical example, and will then demonstrate hypothetically how the case could have been adequately conceptualized and treatment planned.One brief example will illustrate: The patient was an 18-year-old male brought to the hospital after his father interrupted him in the process of attempting to hang himself from a rafter in the garage. The physician’s notes focused on the suicide attempt, vaguely described continuing but fleeting suicidal ideation, “continuing depression” without additional specification , and the titration of a serotonin reuptake inhibitor. No psychotherapy was provided during the hospital stay.
Slide111IMPROVING INPATIENT DOCUMENTATIONThe diagnosis was Mood Disorder NOS. The patient was discharged home on the eighth hospital day, with follow-up by a local mental health clinic. Nowhere in the chart was there documentation of any attempt to understand this young man’s predicament or to develop a comprehensive conceptualization which would provide an understanding of his state of mind and the reasons for his behavior. When the case was discussed by DHCS reviewers with hospital staff they said only, “Well, he was very depressed, he tried to commit suicide. He came to the hospital, and then he received medication treatment.”
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Slide112112IMPROVING INPATIENT DOCUMENTATION Consider just four possible alternative formulations, each of which is described very briefly here:The patient was experiencing the onset of symptoms associated with a first schizophrenic episode, and was terrified of what was happening to him. He felt desperate and did not know what to do.The patient had been sexually molested repeatedly by an uncle, and had recently begun to have thoughts of himself molesting
a young child himself. These thoughts were accompanied by sexual arousal.
Slide113113IMPROVING INPATIENT DOCUMENTATIONThe patient was experiencing Major Depressive Disorder with Melancholic Features, a condition which had led his maternal aunt to commit suicide. He had chosen the anniversary of her suicide as the day on which to commit the act himself.The young man had come to a realization that he was homosexual, and did not believe there was any hope of his living a normal, happy, and fulfilling life. Suicide appeared to him to be his only option.
Slide114IMPROVING INPATIENT DOCUMENTATIONWe will use the outline of this case to construct, hypothetically, the elements necessary to meet medical necessity criteria for inpatient hospital services, as well as to develop a treatment plan which meets federal, State and contractual requirements.Diagnosis: 296.23 Major Depressive Disorder, Single Episode, Severe (Without Psychotic Features), With Melancholic Features114
Slide115IMPROVING INPATIENT DOCUMENTATIONSymptoms Supporting the DiagnosisDepressed mood by self report (feels “empty,” “flat”), which is worse in the morningSignificantly diminished interest in almost all activitiesMarked decrease in reactivity to formerly pleasurable stimuliPronounced psychomotor retardationHypersomnia (sleeps 10-12 hours per day)Feels that what is happening to him is his “fault,” that it could have been avoided had he been “a different sort of person”Cognitive “narrowing” which causes him to believe that death is the only possible “solution” for how he feels
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Slide116IMPROVING INPATIENT DOCUMENTATIONAntecedents to Depressive SymptomsFour weeks prior to the onset of symptoms the patient met an 18-year-old male fellow student in an advanced placement class, and the two of them began spending time together. After two weeks the patient began having “feelings as though I wanted to touch the guy or something.” Over the next two weeks the patient began to realize that he was emotionally and physically attracted to his friend. When he came to the realization that he was gay, he began to feel “afraid.” “I didn’t know what I would say to my dad—he always criticizes homosexuals—he says terrible things about them. I felt embarrassed and really ashamed.”
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Slide117IMPROVING INPATIENT DOCUMENTATIONOver the next two weeks additional symptoms appeared (the feeling of emptiness, intense guilt, an overriding sense of not knowing what to do to “make things right”). The patient began sleeping during the day as well as at night. Finally, he began to think of the possibility of killing himself as his only “way out.” These feelings culminated in his attempt to hang himself in the family garage.117
Slide118IMPROVING INPATIENT DOCUMENTATIONThe Treatment PlanImpairment #1: A recent, interrupted suicide attempt by hanging followed by continuing suicidal ideation without intent or specific plan. The suicidal ideation is related to (a) Feelings of guilt and shame related to his newly recognized identity as a gay man; and (b) Cognitive “narrowing” which causes him to believe that death is the only possible solution for these feelings of guilt and shame. 118
Slide119IMPROVING INPATIENT DOCUMENTATIONGoal 1-1: Decrease frequency of suicidal ideation from the current level of 15-20 times per hour to five or fewer times per hour. Decrease intensity of suicidal ideation from current intensity of 7 on a scale from 1 (very easy to ignore) to 10 (impossible to ignore and results in fantasizing about various specific plans) to 3 or below.Intervention 1-1: Nursing to assess patient each shift to ensure that no suicidal intent or specific plan is reported. If either is reported, notify attending psychologist/psychiatrist immediately and place patient on line of sight observation. Provide a safe, supportive environment. Provide opportunity for conversations with nursing and other staff each shift. Encourage participation in group treatment. Duration: 7 hospital days.
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Slide120IMPROVING INPATIENT DOCUMENTATIONGoal 1-2: Reduce level of guilt and shame from an 8 on a scale from 1 (very mild feelings of guilt/shame which are easily ignored) to 10 (the most severe ever experienced by the patient) to a 4 (unpleasant but tolerable level of guilt/shame). Intervention 1-2: Individual psychotherapy 50 minutes twice per day with staff psychologist. Focus on providing patient with a safe place in which to express his feelings about being gay. Help patient to correct erroneous beliefs/assumptions about sexual orientation. Assist patient in identifying negative self-statements and use cognitive restructuring to replace themwith affirmative alternatives. Duration: 7 hospital days.
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Slide121IMPROVING INPATIENT DOCUMENTATIONGoal 1-3: Reduce “cognitive narrowing” to a point where patient believes (by self report) that there are positive alternatives to his sexual orientation other than suicide.Intervention 1-3: Individual psychotherapy 50 minutes twice per day with staff psychologist. Focus on assisting patient in understanding that cognitive narrowing is a symptom of depression. Provide alternative ways of viewing and understanding what the patient sees as his current “predicament.” Reinforce the notion that these symptoms are transitory and can be modified by psychological and
psychiatric treatment. Duration: 7 hospital days.121
Slide122IMPROVING INPATIENT DOCUMENTATIONImpairment #2: Depressed mood (feeling “empty,” “flat”). Goal 2-1: Reduce level of depressed mood from 8 on a scale from 1 (no depression) to 10 (the worst depression the patient has ever experienced) to a 4.Intervention 2-1: Discontinue the fluvoxamine (Luvox) prescribed by outpatient team: This drug is sedating and will increase patient’s psychomotor retardation. Start patient on fluoxetine (Prozac) 20 mg q AM. Duration: 7 hospital days.
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Slide123IMPROVING INPATIENT DOCUMENTATIONImpairment #3: Hypersomnia.Goal 3-1: Reduce number of hours slept per day from 10-12 to 8-9. Intervention 3-1: Monitor number of hours slept each night and during the day. Encourage participation in recreational therapy. Encourage participation in group exercise program prior to bed time. Duration: 10 hospital days.
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Slide124IMPROVING INPATIENT DOCUMENTATIONImpairment #4: Psychomotor retardation.Goal 4-1: Patient will report an increase in energy level from the current rating of 3 on a scale from 0 (no energy at all) to 10 (his “old, usual, energetic self) to a rating of 6.Intervention 4-1: Fluoxetine as ordered. Daily weights. Report any weight increase(s) to psychiatrist. Encourage participation in recreational and art therapy. Duration: 7 hospital days.
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Slide125IMPROVING INPATIENT DOCUMENTATIONDischarge PlanPatient has agreed to discharge to a crisis residential treatment center, which will allow additional time in which to evaluate potential out-of-home placements. In view of the father’s continuing staunch opposition to and disapproval of his son’s sexual orientation (which he has expressed during family meetings), discharge home is strongly opposed by the treatment team.125
Slide126IMPROVING INPATIENT DOCUMENTATIONPlans for Continuing CareReferral to a gay affirmative psychologist for outpatient assessment and continued individual psychotherapy.Referral to a gay affirmative psychiatrist for continuation of fluoxetine treatment.Provide patient with information regarding the local Gay and Lesbian Community Center for ongoing socialization and support.Provide patient with information on the local suicide prevention hot line and related resources.126
Slide127IMPROVING INPATIENT DOCUMENTATIONIf patient as well as his mother and father are willing, family therapy following discharge from the crisis residential treatment center is recommended. This should be coordinated by his outpatient psychologist.127
Slide128128IMPROVING INPATIENT DOCUMENTATION QUESTIONS